Free INDUSTRIAL COMMISSION OF THE STATE OF IDAHO - Idaho


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State: Idaho
Category: Workers Compensation
Author: Karen Harris
Word Count: 383 Words, 3,317 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.iic.idaho.gov/forms/ic_4006_self_insurance.pdf

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INDUSTRIAL COMMISSION OF THE STATE OF IDAHO APPLICATION WORKERS' COMPENSATION SELF-INSURANCE

Applicant: _________________________________________________________________________ Main Office Address: ________________________________________________________________ Parent Company: ___________________________________________________________________ Adjuster: __________________________________________________________________________ Adjuster Address: ___________________________________________________________________ Three-Year Payroll: 19____: $___________________ 20____: $___________________ 20____: $___________________ Security Deposited: $___________________________ Type: ____________________________ 3-year average payroll $______________

The above-named applicant, a corporation, duly existing under the laws of the State of ______________ desiring to be fully qualified to self-insure in its workers' compensation liability pursuant to Section 72-301, Idaho Code, and respectfully represents: 1. 2. 3. 4. 5. That its previous three-year average annual Idaho payroll, not to include any subsidiary payroll, is in excess of $4,000,000. That it has deposited security in a form and amount as described above. That it has appointed the above-named resident claims adjuster and given it full claims authority as more fully evidenced by a copy of that authorization letter attached. That its last annual statement of assets and liabilities is attached hereto. That it will, at its own expense, keep on hand all forms which are or may be prescribed by the Commission for processing, service, and adjustment of claims and make available to employees such forms as it may require to initiate and perfect claims. That it has delivered to the Idaho State Treasurer a power of attorney authorizing such officer, upon order of a court of competent jurisdiction or of the Industrial Commission, to sell such securities and any of them and disburse the proceeds thereof to any unpaid and deserving claims for which the securities have been deposited. That it will make reports to the Commission as it may require. That it will comply with the statutes of the State of Idaho and rules and regulations of the Industrial Commission to the end that payments of compensation shall be sure and certain and not unnecessarily delayed.

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DATED THIS ________ DAY OF ______________________________, 20_________. X_____________________________________________ By ___________________________________________ ______________________________________________ Title

Industrial Commission of the State of Idaho Workers' Compensation Self-Insurance Application Page Two

STATE OF _______________) COUNTY OF _____________) On this __________ day of ______________________ in the year 20____, before me personally appeared ___________________________________________________________________________ (name of officer) known to me to be the person whose name is subscribed to the within instrument, and acknowledged to me that he executed the same. IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal, this day and year in this certificate first above written ____________________________________________ My commission expires __________________ Notary Public residing at _______________________

IC 4006